In Analytics & Data Management, Coding & Compliance, Medical Billing & Claims, Productivity & Management

Every year CMS requires all MAOs and PDPs to submit multiple “universes” of data to assess the timeliness of their work on a variety of measures. About once every three years, these plans will receive notice that they’ve been selected for a full program audit. The health plans have 15 calendar days to provide dozens of universes with thousands of records of their own and those of delegates.

These universes must be quality controlled to ensure the format of each cell meets CMS requirements, and that the data makes sense (e.g., the claim was not paid before it was received). The work consumes multiple departments–claims, appeals, grievances, utilization management, medical management, care management, compliance, etc.–and many person-hours of time, as each universe must be reviewed manually.

The health plan gets three tries to get the universes right. If they fail, they’ll be cited for Insufficient Data Submission and related findings. Worse, doing poorly on a CMS program audit can result in months of corrective actions, paying for a validation audit to verify corrections, sanctions on enrollment, civil money penalties, and other enforcement actions.

But what if the health plan could use healthcare IT to automate evaluation of each universe within a matter of minutes, and autonomously produce a report of the findings? Well, today that dream is a reality. We can now offer health plans Universe Analytics, which can identify logic errors, format errors, inconsistencies, late cases, cases missing data, and many other crucial areas CMS uses to assess plan universe submissions. It can help any health plan quickly correct and control the quality of submissions to CMS.

Plans can also use Universe Analytics to monitor performance throughout the year or as part of a mock program audit. Delegation oversight can be enhanced with submissions from delegated providers and members to ensure they too are in compliance. This new video covers how Universe Analytics works and why health plans should consider this modern process to manage CMS program audits.

Watch the Video

Change Healthcare announced that it has been awarded a six-year contract by CommonWell Health Alliance® to continue to provide clinical interoperability services to CommonWell to support both treatment and patient access. The new contract extends the existing five-year relationship, whereby CommonWell and Change ...

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